- Email: [email protected]
Results of a 10-Year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial Infarction (from the Korea Acute Myocardial Infarction Registry)
Accepted Manuscript
Results of a 10-year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial (From the Korea Acute Myocardial Infarction Registry) Yongcheol Kim , Myung Ho Jeong , Youngkeun Ahn , Ju han Kim , Young Joon Hong , Doo Sun Sim , Min Chul Kim , Hyo-Soo Kim , Seung Jung Park , Hyeon Cheol Gwon , Kyeong Ho Yun , Seok Kyu Oh , Chong Jin Kim , Myeong Chan Cho , Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators PII: DOI: Reference:
S0002-9149(18)31022-1 10.1016/j.amjcard.2018.04.026 AJC 23267
To appear in:
The American Journal of Cardiology
Received date: Revised date: Accepted date:
27 February 2018 5 April 2018 6 April 2018
Please cite this article as: Yongcheol Kim , Myung Ho Jeong , Youngkeun Ahn , Ju han Kim , Young Joon Hong , Doo Sun Sim , Min Chul Kim , Hyo-Soo Kim , Seung Jung Park , Hyeon Cheol Gwon , Kyeong Ho Yun , Seok Kyu Oh , Chong Jin Kim , Myeong Chan Cho , Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators, Results of a 10-year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial (From the Korea Acute Myocardial Infarction Registry), The American Journal of Cardiology (2018), doi: 10.1016/j.amjcard.2018.04.026
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Results of a 10-year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial (From the Korea Acute Myocardial Infarction Registry) Yongcheol Kim, MD a, Myung Ho Jeong, PhD a *, Youngkeun Ahn, PhD a, Ju han Kim, PhD a,
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Young Joon Hong, PhD a, Doo Sun Sim, PhD a, Min Chul Kim, PhD a, Hyo-Soo Kim, PhD b, Seung Jung Park, PhD c, Hyeon Cheol Gwond, Kyeong Ho Yun, PhD e, Seok Kyu Oh, PhD e, Chong Jin Kim, PhD f, Myeong Chan Cho, PhD g, Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators a
Chonnam National University Hospital, Gwangju, Republic of Korea, bSeoul National
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University Hospital, Seoul, Republic of Korea, cAsan Medical Center, University of Ulsan, Seoul, Republic of Korea, dSungkyunkwan University Samsung Medical Center, Seoul, Republic of Korea, eWonkwang University Hospital, Iksan, Republic of Korea, fKyung Hee University Hospital, Seoul, Republic of Korea, gChungbuk National University Hospital,
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Cheongju, Republic of Korea
*Correspondence: Dr. Myung Ho Jeong, MD, PhD, Principal Investigator of Korea Acute
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Myocardial Infarction Registry, Heart Research Center Nominated by Korea Ministry of Health and Welfare, Chonnam National University Hospital, 671 Jaebongro, Dong-gu,
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Gwangju, 61469, Republic of Korea.
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-E-mail: [email protected] -Tel: (+82) 62-220-6243, Fax: (+82)62-228-7174 *Running head: Trends in PCI for AMI in Korea
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Abstract Limited information exists about characteristics of patients with acute myocardial infarction (AMI) in Asia. We examined trends in interventional treatment and clinical outcomes for AMI in Korean from the Korea Acute Myocardial Infarction Registry (KAMIR). The study
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population was derived from patients in the KAMIR from November 2005 to December 2016. We identified 54,402 patients with ST-elevation myocardial infarction (STEMI) (n = 29,222) and non-ST-elevation myocardial infarction (NSTEMI) (n = 25,180). The rate of percutaneous coronary intervention (PCI) increased to 96.2% of STEMI group and 84.3% of
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NSTEMI group in 2016, respectively (All ptrend < 0.001). Furthermore, the rate of successful PCI was 97.3% in STEMI and 97.9% in NSTEMI. The rate of primary PCI increased from 67.8% in 2005 to 96.9% in 2016 (ptrend < 0.001). Moreover, in patients with STEMI, the
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proportion of drug-eluting stent (DES) implantation increased from 88.8% in 2005 to 97.9% in 2016 (ptrend < 0.001). Regarding one-year clinical outcomes, incidence of definite stent
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thrombosis was 0.5%, 0.6%, and 0.4% in patients with AMI, STEMI, and NSTEMI,
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respectively. Moreover, one-year mortality of AMI improved almost 40% compared with in 2005 (11.4% in 2005 and 6.7% in 2015, ptrend < 0.001). In Korean patients with AMI, the rate
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of primary PCI and DES implantation in STEMI was evidently higher than in the Western registries. In one-year clinical outcomes, the incidence of stent thrombosis was low and
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mortality of AMI gradually improved and was lower than in the Western registries. Key words: Myocardial infarction; Percutaneous coronary intervention; Prognosis
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Introduction Myocardial infarction (MI), one of the main manifestations of coronary artery disease, is a leading cause of mortality in Asia-Pacific region [1]. The incidence rate of MI gradually increased in Asian countries in recent years although it decreased in Western countries [2,3].
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Despite increasing the burden of cardiovascular disease by MI in Asia, a few data are available to reference for treatment and prognosis of MI. The Korea Acute Myocardial Infarction Registry (KAMIR) is a first nationwide, prospective, observational registry reflecting the „real-world‟ clinical field in Korean patients presenting with acute myocardial
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infarction (AMI). We aimed to assess trends in the interventional treatment and clinical outcomes in patients with AMI including ST-elevation myocardial infarction (STEMI) and
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non-ST-elevation myocardial infarction (NSTEMI), respectively, using the KAMIR data.
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Methods
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The KAMIR is, launched in November 2005, is a multicenter online data collection registry designed to examine the characteristics, treatment practice, and outcomes in patients
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presenting AMI. Online registration of cases of AMI at the web site of www.kamir.or.kr has
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been carried out in community and teaching hospitals with facilities for primary percutaneous coronary intervention (PCI) and on-site cardiac surgery. Data were collected at each site by a trained study coordinator based on the standardized protocol retrospectively. AMI was based on increase and/or decrease level of cardiac biomarker, including creatine kinase-MB and troponin I or T, with either ischemic symptoms or electrocardiographic 3
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changes including ST-segment deviation and development of pathologic Q waves. STEMI was defined as new ST-segment elevation > 0.1 mV in ≥ 2 contiguous leads, a new left bundle branch block on 12-lead electrocardiogram with a concomitant increase in cardiac markers.
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This study protocols were approved by the ethics committee at each participating center, and followed the principles of the Declaration of Helsinki. Written informed consent was given by each patient.
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Data of medication on hospitalization and coronary angiographic and procedural characteristics were recorded. During the in-hospital period, in-hospital mortality including cardiac and non-cardiac death was recorded. Regarding one-year clinical outcomes, incidence of definite stent thrombosis, all-cause mortality, MI, repeat PCI, and coronary artery bypass
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surgery (CABG) was collected in patients enrolled between November 2005 and December
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2015.
Continuous variables were expressed as mean with standard deviation or median with
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interquartile ranges, when appropriate. Categorical variables were reported as numbers with
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percentage and compared with χ2 test or Fisher exact test. Continuous variables were analyzed using the unpaired t-test or Mann-Whitney U test, as appropriate. Trends were
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analysis using linear-by-linear association test for binary and Jonckheere-Terpstra tests for continuous variables. All of the analyses were two-tailed, with clinical significance defined as P < 0.05. Statistical analysis was performed using SPSS 22.0 for Windows (SPSS-PC, Chicago, IL, USA).
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Results The study population was derived from patients in the KAMIR enrolled from November 2005 to December 2016. A total of 56,559 consecutively listed patients were enrolled in the KAMIR. However, we later excluded 2,157 patients as 615 were not final diagnosed with MI,
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92 did not have determined study day, and 1450 were not classified STEMI or NSTEMI. Therefore, altogether 54,402 patients were included in this study (Figure S1 in Supplementary material). The total number of patients excluded from the analysis was 2,157 (3.81%). Of 54,402 AMI, 29,222 (53.7%) presented with STEMI and 25,180 (46.3%)
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presented with NSTEMI. Overall mean age of the population of the population was 63.5 years and 71.9% were male.
Procedural and coronary angiographic characteristics and in-hospital outcomes are shown
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in table 1. Transradial approach was used in 29.5% of the patients with AMI in study period.
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Radial access increased markedly from 17.9% in 2008 to 56.1% in 2016 (ptrend < 0.001; Figure 1A). This tendency was also observed in both STEMI and NSTEMI groups (Figure
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1B and C). In STEMI group, transradial approach increased from 16.0% in 2008 to 46.0% in 2016, but there was not over 50.0% (ptrend < 0.001; Figure 1B). On the other hand, in
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NSTEMI group, transradial approach increased from 21.0% in 2008 to 66.5% in 2016 and
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radial access overtook femoral access in 2014 (ptrend < 0.001; Figure 1C). Among 27,669 patients presenting with STEMI, 24,269 (87.8%) were treated by primary
PCI. The rate of primary PCI increased from 67.8% in 2005 to 96.9% in 2016 (ptrend < 0.001; Figure 2A). PCI was performed PCI in 87.3%, 93.6% and 80.0% of patients with AMI and both STEMI and NSTEMI, respectively. Moreover, the rate of PCI gradually increased from 5
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82.0%, 87.0%, and 73.1% in 2005 to 90.0%, 96.2%, and 84.3% in 2016 (All ptrend < 0.001; Figure 2B). The rate of successful PCI and achievement of post-PCI Thrombolysis In Myocardial Infarction (TIMI) 3 flow were 97.6% and 93.1% in patients with AMI, respectively. The most common infarct-related artery was left anterior descending artery in
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patients with AMI (47.1%) including STEMI (51.2%) and NSTEMI (41.7%), respectively. Target lesion was treated with stent implantation in 90.3% of patients with AMI and the use of drug-eluting stent (DES) was over 90.0% in patients with AMI including STEMI and NSTEMI, respectively. In addition, in patients with STEMI who underwent PCI with stent,
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the proportion of DES implantation increased from 88.8% in 2005 to 97.9% in 2016 (ptrend < 0.001; Figure 3).
Regarding in-hospital outcomes, the mean length of hospital stay was 8.2 days in patients
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with AMI and not different in STEMI and NSTEMI groups. In-hospital mortality rate is higher in patients with STEMI than in those with NSTEMI (5.7% vs. 3.3%). Cardiac death
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was dominant in both groups, respectively.
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Discharge medications of antiplatelet are shown in Table 2. Most of all patients were treated with aspirin. P2Y2 receptor antagonist and dual antiplatelet therapy, consisting of the
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combination of aspirin and P2Y12 receptor inhibitor, were more frequently prescribed for STEMI patients. Among new P2Y12 receptor inhibitor, ticagrelor was more prescribed than
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prasugrel in all patients. One-year clinical outcomes from 2005 to 2015 are shown Table 3. In patients with AMI,
one-year mortality was 10.6%, including cardiac (8.0%) and non-cardiac death (2.6%), followed by repeat PCI (5.5%), MI (1.7%), and CABG (0.4%). Mortality was higher in 6
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patients with STEMI than in those in NSTEMI, but MI and CABG were more frequently occurred in NSTEMI group. However, the incidence of non-cardiac death and repeat PCI were not different in both groups. Regarding the trend analysis of one-year clinical outcomes, in patients with AMI including
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STEMI and NSTEMI, mortality was decreased from 11.4%, 11.9%, 10.6% in 2005 to 6.7%, 7.5%, 6.0% in 2015, respectively (All ptrend < 0.001; Figure 4). Trends of cardiac death also decreased in 2015 when compared with those in 2005 in AMI including both STEMI and NSTEMI groups (All ptrend < 0.001; Figure S2 in Supplementary material). The incidence of
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definite stent thrombosis was 0.5% in patients with AMI and was not different in 0.6% and
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0.4% of STEMI and NSTEMI group, respectively.
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Discussion
This nationwide cohort study documents changes in the treatment strategy and clinical
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outcomes in Korean population for about 10 years. In terms of vascular access, we reported that radial approach had lower complication rate and better clinical outcomes in octogenarian
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patients with AMI [4].
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In present study, interventional strategies showed notably different characteristics compared with Western AMI registries. The French AMI registry documented that the incidence of PCI was performed in 77%, 86%, 66% of patients with AMI and both STEMI and NSTEMI in 2010, respectively, and it did not quite change to 78%, 90%, and 60% in 2015, respectively [5,6]. Furthermore, French registry showed lower rates of primary PCI 7
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than in our registry (64% vs. 92.6% in 2010 and 76% vs. 97.0% in 2015) [6]. In another two Western registries, Sweden and the United Kingdom (UK), between 2004 and 2010, the rates of primary PCI were just 59.3% and 22.4% in Swedish and UK patients [7]. Regarding primary PCI, we found that total ischemic time, symptom-to-balloon time, below 180
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minutes was an independent predictor of one-month mortality after primary PCI [8]. We also reported that the equipoise between pharmacoinvasive strategy and primary PCI for one-year clinical outcomes when PCI-related delay [9].
In our study, left main or multivessel disease (MVD) were about half of patients with AMI
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including both STEMI and NSTEMI. Regarding MVD, we reported that obstructive nonculprit artery disease was significant associated with an increased risk of thirty-day mortality in patients with STEMI in KAMIR registry, but not in Duke registry [10]. Furthermore,
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Staged PCI with complete revascularization during index hospitalization was improved threeyear clinical outcomes for patients with STEMI and MVD in our previous study [11].
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Multivessel PCI also showed better clinical outcomes in patients with MVD presenting with NSTEMI and in patients with STEMI with cardiogenic shock with MVD compared to
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culprit-only revascularization, supporting current revascularization guidelines [12-14]. In
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terms of clinical impact of thrombus aspiration, we reported that thrombus aspiration was associated with lower one-year clinical outcomes in patients undergoing reperfusion between
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four and six hour after symptom onset [15]. Moreover, thrombus aspiration for left anterior descending artery as culprit lesion was effective and combined use of glycoprotein IIb/IIIa inhibitor with thrombus aspiration had a synergistic effect [16]. In terms of intravascular imaging-guided PCI, intravascular ultrasound-guided PCI did not improved one-year clinical outcomes in patients with AMI in our previous study [17]. 8
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The proportion of DES implantation was markedly high in all patients. Especially, the use of DES implantation was over 95.0% in patients with STEMI since 2011 (Figure 3). The rate of DES implantation was just 52% in the trial of routine aspiration ThrOmbecTomy with PCI versus PCI Alone in patient with STEMI (TOTAL), which was enrolled in 20 Western
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hospitals between 2010 and 2014. TOTAL trial found that the use of DES was associated with better clinical outcomes compared to the use of bare metal stent [18]. With several studies from KAMIR registry, the efficacy and safety of DES in patient with AMI was also reported [19-22]. In present study, definite stent thrombosis was < 1.0% in patients with AMI
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including both STEMI and NSTEMI, respectively. Therefore, low incidence of sent thrombosis potentially can be explained by high rate of DES implantation. In terms of medication prescribed, clopidogrel was mainly prescribed among P2Y12
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receptor inhibitor as ticagrelor and prasugrel were available since 2011 in Korea. In terms of new P2Y12 receptor inhibitor, we reported that ticagrelor and prasugrel were associated with
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increased bleeding risk without reducing ischemic events in patient with AMI [23,24].
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The one-year mortality for patients with AMI decreased and this decline was also observed in both STEMI and NSTEMI groups (Figure 4). In the Danish registry, one-year mortality
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decreased continuously from 2003 to 2012 in patients with AMI [25]. However, higher oneyear mortality in 2012 was observed, 15.7%, 8.0%, and 19.7% in AMI, STEMI, and NSTEMI
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groups, respectively, in the Danish registry, compared with those of the our data, 7.8%, 7.9%, and 7.7%. In Swedish registry, one-year mortality of STEMI group decreased from 22.1% in 1995-1996 to 14.1% in 2013-2014, but it was still higher than our data, 8.0% in 2014 [26]. With the difference of long-term clinical outcomes from Western registries, we developed a new risk score, KAMIR score, had more simplicity and accuracy for one-year mortality in 9
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Korea patients with AMI than the TIMI and Global Registry of Acute Coronary Events (GRACE) score [27,28]. Our study has limitations. First, selection bias cannot be avoided due to a retrospective observational study. Second, in order to reflect the real-world clinical data in patients with
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AMI, indexes were updated several times during study period. As a result, some of index, had less number of enrolled patients compared with other indexes and residual confounding also was remained. Nonetheless, it could be possible to understand the trends of patients with AMI
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because of large number of enrolled patients.
In conclusion, our study showed several trends of characteristics in Korean patients with AMI. Our findings provide information and evidence regarding management and treatment for Korean patients with AMI. In addition, guidelines for Asian patients with AMI should be
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Acknowledgments
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needed due to the differences in between Asia and Western patients with AMI.
This study was performed with the support of the Korean Circulation Society (KCS) as a
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memorandum of the 50th Anniversary of the KCS and the Korean Ministry of Health and
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Welfare, Republic of Korea.
Disclosures
The authors have no conflict of interest to disclose.
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27.
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Choi DH, Cho MC, Kim CJ, Seung KB, Chung WS, Jang YS, Rha SW, Bae JH, Cho JG, Park SJ; Other Korea Acute Myocardial Infarction Registry Investigation. Hospital discharge risk score system for the assessment of clinical outcomes in patients with acute myocardial infarction (Korea Acute Myocardial Infarction Registry [KAMIR] score). Am J Cardiol 2011;107:965-971.e1. 16
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Kim HK, Jeong MH, Ahn Y, Kim JH, Chae SC, Kim YJ, Hur SH, Seong IW, Hong TJ, Choi DH, Cho MC, Kim CJ, Seung KB, Chung WS, Jang YS, Rha SW, Bae JH, Cho JG, Park SJ; other Korea Acute Myocardial Infarction Registry Investigators; Korea Acute Myocardial Infarction Registry (KAMIR) Study Group of Korean Circulation
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Society. A new risk score system for the assessment of clinical outcomes in patients with non-ST-segment elevation myocardial infarction. Int J Cardiol 2010;145:450-
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454.
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Figure legends
Figure 1. Changing trends in vascular access in patients with AMI (A), STEMI (B), and 18
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NSTEMI (C). Abbreviations: AMI, acute myocardial infarction; NSTEMI, non-ST-elevation myocardial
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infarction; STEMI, ST-elevation myocardial infarction.
Figure 2. Annual primary PCI rate in patients with STEMI (A), PCI rates in patients with 19
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AMI and both STEMI and NSTEMI (B). Abbreviation: AMI, acute myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction; PCI, percutaneous coronary
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intervention.
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Figure 3. The proportion of DES and BMS implantation in patients with STEMI from 2005
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and 2016. Abbreviations: BMS, bare metal stent; DES, drug-eluting stent; STEMI, ST-
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elevation myocardial infarction.
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Figure 4. Temporal trend in one-year mortality between 2005 and 2015.
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Table 1. Procedural and coronary angiographic characteristics and in-hospital outcomes of patients hospitalized with AMI between 2005 and 2016.
AMI (n=54,402)
Total
No.
no. Primary PCI for
STEMI
NSTEMI
(n=29,222)
(n=25,180)
Total no.
-
27,669
STEMI
24,296
-
18,877
4,658
-
(24.7%)
Radial access
34,223
10,100
Image-guided PCI
34,611
19,124
7,394
18,204
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(21.4%)
53,754
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Performed PCI
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45,735
Post-PCI TIMI 3
43,624
flow
46,941
29,090
26,574
16,407
27,217
25,851
25,263
23,254
24,664
coronary artery
22
<0.001
(38.0%) 3,626
0.001
19,724
<0.001
(80.0%) 19,161
18,765
<0.001
(97.9%) 18,361
(92.0%) 27,067
5,744
(22.1%)
(97.3%)
(93.1%) 47,240
3,768
(93.6%)
(97.6%) 40,607
15,099
(20.7%)
(87.3%) 44,616
4,356
(22.8%)
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(29.5%)
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No.
no.
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-
aspiration
Infarct-related
Total
Value*
(87.8%)
Thrombus
Successful PCI
No.
p
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Variables
17,353
<0.001
(94.5%) 20,173
<0.001
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descending Left circumflex
Right
Left main
Involved
vessel
22,263
13,848
8,415
(47.1%)
(51.2%)
(41.7%)
8,044
2,623
5,421
(17.0%)
(9.7%)
(26.9%)
15,834
10,144
5,690
(33.5%)
(37.5%)
(28.2%)
1,099
452
647
(2.3%)
(1.7%)
47,124
26,989
type Single vessel
21,667 (46.0%)
main
or
25,457
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Left
(54.0%)
ACC/AHA B2/C
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multivessel 43,440
46,566
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Stenting for target lesion
24,825
(80.6%)
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lesion
35,000
42,027
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anterior
(3.2%)
20,135
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Left
13,519
8,148
(50.1%)
(40.5%)
13,470
11,987
(49.9%)
(59.5%)
20,213
18,615
(81.4%) 26,872
<0.001
24,651
14,787 (79.4%)
19,684
17,376
(90.3%)
(91.7%)
(88.3%)
38,772
22,592
16,180
(94.0%)
(93.5%)
(94.8%)
2,367
1,527
840
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Type of implanted stent
Drug-eluting
stent Bare-metal stent
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<0.001
<0.001
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(5.8%)
(6.3%)
(4.9%)
Bioresorbable
87
43
44
vascular scaffold
(0.2%)
(0.2%)
(0.3%)
Implanted
stent,
No. of stents per 13,869 target lesion
(0.43%)
diameter 41,469
per lesion, mm Stented
3.15
length
41,087
26.3 (10.3%)
No. of stents per 43,541
(0.85%)
outcomes
51,352
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Length of stay, mean (SD), days
54,059
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In-hospital death
Cardiac death†
6,677
3.19
24,113
26.1
17,136
1.36
3.09
16,974
18,904
26.6
1.44 (0.96%)
8.2
8.2
8.3
(9.5%)
(9.6%)
(9.4%)
28,990
1,650
25,069
828
(4.6%)
(5.7%)
(3.3%)
1,972
1,365
607
(79.6%)
(82.7%)
(73.3%)
507
285
221
(20.4%)
(17.3%)
(26.7%)
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<0.001
<0.001
(11.4%)
(0.75%)
2,478
<0.001
(0.44%)
(9.4%)
24,637
1.21
(0.46%)
(0.44%)
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In-hospital
Non-cardiac
24,333
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patient
1.40
1.17
(0.40%)
(0.44%)
per lesion, mm
death‡
7,192
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Stent
1.19
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mean (SD)
<0.001
0.057
<0.001
<0.001
<0.001
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Data are expressed as No. (%) unless otherwise indicated * † ‡
STEMI vs. NSTEMI. Pump failure, arrhythmia, and mechanical complication. Multi-organ failure, bleeding, sepsis, others.
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Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; AMI, acute myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIMI, Thrombolysis In
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Myocardial Infarction.
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Table 2. Antiplatelet medications at discharge between 2005 and 2016.
STEMI
NSTEMI
(n=54,402)
(n=29,222)
(n=25,180)
Total
No.
Total
no. DAPT
no.
49,332
45,339
26,347
(91.9%) 49,541
48,166 (97.2%)
P2Y12
49,249
receptor
46,039 (93.5%)
Clopidogrel
46,039
40,986
26,353
25,270
ED 3,622
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46,039
(7.9%)
46,039
1,431
25,270
22,487
1,955
22,896
20,769
(3.1%)
828
<0.001
22,303
<0.001
(96.5%) 20,769
<0.001
(90.7%)
18,499
0.78
(89.1%) 20,769
(7.7%) 25,270
20,603
1,667
0.250
(8.0%) 20,769
(3.3%)
603
0.022
(2.9%)
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Prasugrel
23,101
(89.0%) 25,270
Value*
(89.6%)
(95.9%)
(89.0%)
Ticagrelor
25,863
22,985
(97.8%)
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inhibitor
24,796
p
No.
no.
(94.1%) 26,440
Total
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Aspirin
No.
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Variable
AMI
Data expressed as No. (%) *
STEMI vs. NSTEMI.
Abbreviations: AMI, acute myocardial infarction; DAPT, dual antiplatelet therapy; NSTEMI, non-STelevation myocardial infarction; STEMI, ST-elevation myocardial infarction.
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Table 3. One-year cumulative clinical outcomes from 2005 to 2015. STEMI
NSTEMI
(n=51,019)
(n=29,222)
(n=25,180)
Total
No.
no.
Total
No.
no.
One-year follow-
18,271
3,630 (10.6%)
Cardiac death†
34,337
2,758 (8.0%)
34,337
death ‡ 34,337
infarction
PT
590
590
AC
NSTEMI
34,337
CABG
34,337
Repeat PCI
590
197
18,271
18,271
243
243
460
16,066
(2.5%) 243
140
103
18,271
1,031
16,066
(0.4%)
54 (0.3%)
27
<0.001
(9.5%) 1,119
<0.001
(7.0%) 412
0.53
347
<0.001
(2.2%) 347
57
<0.001
(16.4%) 347
290
<0.001
(83.6%) 16,066
(5.6%) 18,271
1,531
(2.6%)
(42.4%)
(5.5%) 129
16,066
(57.6%)
(66.6%) 1,880
1,639
(1.3%)
(33.4%) 393
16,066
(9.0%)
(1.7%)
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STEMI
18,271
(2.6%)
ED
Myocardial
872
2,099 (11.5%)
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Non-cardiac
18,271
Value*
16,066
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34,337
p
No.
no.
up All-cause death
Total
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Variables
AMI
849
0.18
(5.3%) 16,066
75 (0.5%)
0.010
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stent
28,883
thrombosis
147
86
61
(0.5%)
(0.6%)
(0.4%)
Type of definite
0.097
0.051
stent thrombosis 147
14
86
8 (9.3%)
86
42
(9.5%) Subacute
147
59 (40.1%)
147
55 (40.5%)
Very late
147
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Data expressed as number (%).
†
(12.8%)
0.011
61
61
30
0.013
(49.2%) 8
0.95
(13.1%)
Pump failure, arrhythmia, mechanical complication. Multi-organ failure, bleeding, sepsis, others.
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‡
STEMI vs. NSTEMI.
11
17
(27.9%)
(29.1%)
86
0.91
ED
*
25
6 (9.8%)
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(12.9%)
86
61
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Late
(48.8%)
61
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Acute
Abbreviations: AMI, acute myocardial infarction; CABG, coronary-artery bypass surgery; NSTEMI,
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non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-
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elevation myocardial infarction.
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Results of a 10-year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial (From the Korea Acute Myocardial Infarction Registry) Yongcheol Kim , Myung Ho Jeong , Youngkeun Ahn , Ju han Kim , Young Joon Hong , Doo Sun Sim , Min Chul Kim , Hyo-Soo Kim , Seung Jung Park , Hyeon Cheol Gwon , Kyeong Ho Yun , Seok Kyu Oh , Chong Jin Kim , Myeong Chan Cho , Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators PII: DOI: Reference:
S0002-9149(18)31022-1 10.1016/j.amjcard.2018.04.026 AJC 23267
To appear in:
The American Journal of Cardiology
Received date: Revised date: Accepted date:
27 February 2018 5 April 2018 6 April 2018
Please cite this article as: Yongcheol Kim , Myung Ho Jeong , Youngkeun Ahn , Ju han Kim , Young Joon Hong , Doo Sun Sim , Min Chul Kim , Hyo-Soo Kim , Seung Jung Park , Hyeon Cheol Gwon , Kyeong Ho Yun , Seok Kyu Oh , Chong Jin Kim , Myeong Chan Cho , Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators, Results of a 10-year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial (From the Korea Acute Myocardial Infarction Registry), The American Journal of Cardiology (2018), doi: 10.1016/j.amjcard.2018.04.026
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Results of a 10-year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial (From the Korea Acute Myocardial Infarction Registry) Yongcheol Kim, MD a, Myung Ho Jeong, PhD a *, Youngkeun Ahn, PhD a, Ju han Kim, PhD a,
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Young Joon Hong, PhD a, Doo Sun Sim, PhD a, Min Chul Kim, PhD a, Hyo-Soo Kim, PhD b, Seung Jung Park, PhD c, Hyeon Cheol Gwond, Kyeong Ho Yun, PhD e, Seok Kyu Oh, PhD e, Chong Jin Kim, PhD f, Myeong Chan Cho, PhD g, Other Korea Acute Myocardial Infarction Registry (KAMIR) Investigators a
Chonnam National University Hospital, Gwangju, Republic of Korea, bSeoul National
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University Hospital, Seoul, Republic of Korea, cAsan Medical Center, University of Ulsan, Seoul, Republic of Korea, dSungkyunkwan University Samsung Medical Center, Seoul, Republic of Korea, eWonkwang University Hospital, Iksan, Republic of Korea, fKyung Hee University Hospital, Seoul, Republic of Korea, gChungbuk National University Hospital,
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Cheongju, Republic of Korea
*Correspondence: Dr. Myung Ho Jeong, MD, PhD, Principal Investigator of Korea Acute
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Myocardial Infarction Registry, Heart Research Center Nominated by Korea Ministry of Health and Welfare, Chonnam National University Hospital, 671 Jaebongro, Dong-gu,
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Gwangju, 61469, Republic of Korea.
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-E-mail: [email protected] -Tel: (+82) 62-220-6243, Fax: (+82)62-228-7174 *Running head: Trends in PCI for AMI in Korea
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Abstract Limited information exists about characteristics of patients with acute myocardial infarction (AMI) in Asia. We examined trends in interventional treatment and clinical outcomes for AMI in Korean from the Korea Acute Myocardial Infarction Registry (KAMIR). The study
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population was derived from patients in the KAMIR from November 2005 to December 2016. We identified 54,402 patients with ST-elevation myocardial infarction (STEMI) (n = 29,222) and non-ST-elevation myocardial infarction (NSTEMI) (n = 25,180). The rate of percutaneous coronary intervention (PCI) increased to 96.2% of STEMI group and 84.3% of
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NSTEMI group in 2016, respectively (All ptrend < 0.001). Furthermore, the rate of successful PCI was 97.3% in STEMI and 97.9% in NSTEMI. The rate of primary PCI increased from 67.8% in 2005 to 96.9% in 2016 (ptrend < 0.001). Moreover, in patients with STEMI, the
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proportion of drug-eluting stent (DES) implantation increased from 88.8% in 2005 to 97.9% in 2016 (ptrend < 0.001). Regarding one-year clinical outcomes, incidence of definite stent
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thrombosis was 0.5%, 0.6%, and 0.4% in patients with AMI, STEMI, and NSTEMI,
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respectively. Moreover, one-year mortality of AMI improved almost 40% compared with in 2005 (11.4% in 2005 and 6.7% in 2015, ptrend < 0.001). In Korean patients with AMI, the rate
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of primary PCI and DES implantation in STEMI was evidently higher than in the Western registries. In one-year clinical outcomes, the incidence of stent thrombosis was low and
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mortality of AMI gradually improved and was lower than in the Western registries. Key words: Myocardial infarction; Percutaneous coronary intervention; Prognosis
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Introduction Myocardial infarction (MI), one of the main manifestations of coronary artery disease, is a leading cause of mortality in Asia-Pacific region [1]. The incidence rate of MI gradually increased in Asian countries in recent years although it decreased in Western countries [2,3].
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Despite increasing the burden of cardiovascular disease by MI in Asia, a few data are available to reference for treatment and prognosis of MI. The Korea Acute Myocardial Infarction Registry (KAMIR) is a first nationwide, prospective, observational registry reflecting the „real-world‟ clinical field in Korean patients presenting with acute myocardial
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infarction (AMI). We aimed to assess trends in the interventional treatment and clinical outcomes in patients with AMI including ST-elevation myocardial infarction (STEMI) and
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non-ST-elevation myocardial infarction (NSTEMI), respectively, using the KAMIR data.
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Methods
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The KAMIR is, launched in November 2005, is a multicenter online data collection registry designed to examine the characteristics, treatment practice, and outcomes in patients
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presenting AMI. Online registration of cases of AMI at the web site of www.kamir.or.kr has
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been carried out in community and teaching hospitals with facilities for primary percutaneous coronary intervention (PCI) and on-site cardiac surgery. Data were collected at each site by a trained study coordinator based on the standardized protocol retrospectively. AMI was based on increase and/or decrease level of cardiac biomarker, including creatine kinase-MB and troponin I or T, with either ischemic symptoms or electrocardiographic 3
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changes including ST-segment deviation and development of pathologic Q waves. STEMI was defined as new ST-segment elevation > 0.1 mV in ≥ 2 contiguous leads, a new left bundle branch block on 12-lead electrocardiogram with a concomitant increase in cardiac markers.
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This study protocols were approved by the ethics committee at each participating center, and followed the principles of the Declaration of Helsinki. Written informed consent was given by each patient.
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Data of medication on hospitalization and coronary angiographic and procedural characteristics were recorded. During the in-hospital period, in-hospital mortality including cardiac and non-cardiac death was recorded. Regarding one-year clinical outcomes, incidence of definite stent thrombosis, all-cause mortality, MI, repeat PCI, and coronary artery bypass
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surgery (CABG) was collected in patients enrolled between November 2005 and December
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2015.
Continuous variables were expressed as mean with standard deviation or median with
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interquartile ranges, when appropriate. Categorical variables were reported as numbers with
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percentage and compared with χ2 test or Fisher exact test. Continuous variables were analyzed using the unpaired t-test or Mann-Whitney U test, as appropriate. Trends were
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analysis using linear-by-linear association test for binary and Jonckheere-Terpstra tests for continuous variables. All of the analyses were two-tailed, with clinical significance defined as P < 0.05. Statistical analysis was performed using SPSS 22.0 for Windows (SPSS-PC, Chicago, IL, USA).
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Results The study population was derived from patients in the KAMIR enrolled from November 2005 to December 2016. A total of 56,559 consecutively listed patients were enrolled in the KAMIR. However, we later excluded 2,157 patients as 615 were not final diagnosed with MI,
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92 did not have determined study day, and 1450 were not classified STEMI or NSTEMI. Therefore, altogether 54,402 patients were included in this study (Figure S1 in Supplementary material). The total number of patients excluded from the analysis was 2,157 (3.81%). Of 54,402 AMI, 29,222 (53.7%) presented with STEMI and 25,180 (46.3%)
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presented with NSTEMI. Overall mean age of the population of the population was 63.5 years and 71.9% were male.
Procedural and coronary angiographic characteristics and in-hospital outcomes are shown
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in table 1. Transradial approach was used in 29.5% of the patients with AMI in study period.
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Radial access increased markedly from 17.9% in 2008 to 56.1% in 2016 (ptrend < 0.001; Figure 1A). This tendency was also observed in both STEMI and NSTEMI groups (Figure
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1B and C). In STEMI group, transradial approach increased from 16.0% in 2008 to 46.0% in 2016, but there was not over 50.0% (ptrend < 0.001; Figure 1B). On the other hand, in
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NSTEMI group, transradial approach increased from 21.0% in 2008 to 66.5% in 2016 and
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radial access overtook femoral access in 2014 (ptrend < 0.001; Figure 1C). Among 27,669 patients presenting with STEMI, 24,269 (87.8%) were treated by primary
PCI. The rate of primary PCI increased from 67.8% in 2005 to 96.9% in 2016 (ptrend < 0.001; Figure 2A). PCI was performed PCI in 87.3%, 93.6% and 80.0% of patients with AMI and both STEMI and NSTEMI, respectively. Moreover, the rate of PCI gradually increased from 5
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82.0%, 87.0%, and 73.1% in 2005 to 90.0%, 96.2%, and 84.3% in 2016 (All ptrend < 0.001; Figure 2B). The rate of successful PCI and achievement of post-PCI Thrombolysis In Myocardial Infarction (TIMI) 3 flow were 97.6% and 93.1% in patients with AMI, respectively. The most common infarct-related artery was left anterior descending artery in
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patients with AMI (47.1%) including STEMI (51.2%) and NSTEMI (41.7%), respectively. Target lesion was treated with stent implantation in 90.3% of patients with AMI and the use of drug-eluting stent (DES) was over 90.0% in patients with AMI including STEMI and NSTEMI, respectively. In addition, in patients with STEMI who underwent PCI with stent,
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the proportion of DES implantation increased from 88.8% in 2005 to 97.9% in 2016 (ptrend < 0.001; Figure 3).
Regarding in-hospital outcomes, the mean length of hospital stay was 8.2 days in patients
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with AMI and not different in STEMI and NSTEMI groups. In-hospital mortality rate is higher in patients with STEMI than in those with NSTEMI (5.7% vs. 3.3%). Cardiac death
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was dominant in both groups, respectively.
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Discharge medications of antiplatelet are shown in Table 2. Most of all patients were treated with aspirin. P2Y2 receptor antagonist and dual antiplatelet therapy, consisting of the
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combination of aspirin and P2Y12 receptor inhibitor, were more frequently prescribed for STEMI patients. Among new P2Y12 receptor inhibitor, ticagrelor was more prescribed than
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prasugrel in all patients. One-year clinical outcomes from 2005 to 2015 are shown Table 3. In patients with AMI,
one-year mortality was 10.6%, including cardiac (8.0%) and non-cardiac death (2.6%), followed by repeat PCI (5.5%), MI (1.7%), and CABG (0.4%). Mortality was higher in 6
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patients with STEMI than in those in NSTEMI, but MI and CABG were more frequently occurred in NSTEMI group. However, the incidence of non-cardiac death and repeat PCI were not different in both groups. Regarding the trend analysis of one-year clinical outcomes, in patients with AMI including
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STEMI and NSTEMI, mortality was decreased from 11.4%, 11.9%, 10.6% in 2005 to 6.7%, 7.5%, 6.0% in 2015, respectively (All ptrend < 0.001; Figure 4). Trends of cardiac death also decreased in 2015 when compared with those in 2005 in AMI including both STEMI and NSTEMI groups (All ptrend < 0.001; Figure S2 in Supplementary material). The incidence of
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definite stent thrombosis was 0.5% in patients with AMI and was not different in 0.6% and
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0.4% of STEMI and NSTEMI group, respectively.
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Discussion
This nationwide cohort study documents changes in the treatment strategy and clinical
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outcomes in Korean population for about 10 years. In terms of vascular access, we reported that radial approach had lower complication rate and better clinical outcomes in octogenarian
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patients with AMI [4].
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In present study, interventional strategies showed notably different characteristics compared with Western AMI registries. The French AMI registry documented that the incidence of PCI was performed in 77%, 86%, 66% of patients with AMI and both STEMI and NSTEMI in 2010, respectively, and it did not quite change to 78%, 90%, and 60% in 2015, respectively [5,6]. Furthermore, French registry showed lower rates of primary PCI 7
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than in our registry (64% vs. 92.6% in 2010 and 76% vs. 97.0% in 2015) [6]. In another two Western registries, Sweden and the United Kingdom (UK), between 2004 and 2010, the rates of primary PCI were just 59.3% and 22.4% in Swedish and UK patients [7]. Regarding primary PCI, we found that total ischemic time, symptom-to-balloon time, below 180
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minutes was an independent predictor of one-month mortality after primary PCI [8]. We also reported that the equipoise between pharmacoinvasive strategy and primary PCI for one-year clinical outcomes when PCI-related delay [9].
In our study, left main or multivessel disease (MVD) were about half of patients with AMI
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including both STEMI and NSTEMI. Regarding MVD, we reported that obstructive nonculprit artery disease was significant associated with an increased risk of thirty-day mortality in patients with STEMI in KAMIR registry, but not in Duke registry [10]. Furthermore,
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Staged PCI with complete revascularization during index hospitalization was improved threeyear clinical outcomes for patients with STEMI and MVD in our previous study [11].
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Multivessel PCI also showed better clinical outcomes in patients with MVD presenting with NSTEMI and in patients with STEMI with cardiogenic shock with MVD compared to
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culprit-only revascularization, supporting current revascularization guidelines [12-14]. In
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terms of clinical impact of thrombus aspiration, we reported that thrombus aspiration was associated with lower one-year clinical outcomes in patients undergoing reperfusion between
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four and six hour after symptom onset [15]. Moreover, thrombus aspiration for left anterior descending artery as culprit lesion was effective and combined use of glycoprotein IIb/IIIa inhibitor with thrombus aspiration had a synergistic effect [16]. In terms of intravascular imaging-guided PCI, intravascular ultrasound-guided PCI did not improved one-year clinical outcomes in patients with AMI in our previous study [17]. 8
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The proportion of DES implantation was markedly high in all patients. Especially, the use of DES implantation was over 95.0% in patients with STEMI since 2011 (Figure 3). The rate of DES implantation was just 52% in the trial of routine aspiration ThrOmbecTomy with PCI versus PCI Alone in patient with STEMI (TOTAL), which was enrolled in 20 Western
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hospitals between 2010 and 2014. TOTAL trial found that the use of DES was associated with better clinical outcomes compared to the use of bare metal stent [18]. With several studies from KAMIR registry, the efficacy and safety of DES in patient with AMI was also reported [19-22]. In present study, definite stent thrombosis was < 1.0% in patients with AMI
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including both STEMI and NSTEMI, respectively. Therefore, low incidence of sent thrombosis potentially can be explained by high rate of DES implantation. In terms of medication prescribed, clopidogrel was mainly prescribed among P2Y12
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receptor inhibitor as ticagrelor and prasugrel were available since 2011 in Korea. In terms of new P2Y12 receptor inhibitor, we reported that ticagrelor and prasugrel were associated with
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increased bleeding risk without reducing ischemic events in patient with AMI [23,24].
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The one-year mortality for patients with AMI decreased and this decline was also observed in both STEMI and NSTEMI groups (Figure 4). In the Danish registry, one-year mortality
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decreased continuously from 2003 to 2012 in patients with AMI [25]. However, higher oneyear mortality in 2012 was observed, 15.7%, 8.0%, and 19.7% in AMI, STEMI, and NSTEMI
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groups, respectively, in the Danish registry, compared with those of the our data, 7.8%, 7.9%, and 7.7%. In Swedish registry, one-year mortality of STEMI group decreased from 22.1% in 1995-1996 to 14.1% in 2013-2014, but it was still higher than our data, 8.0% in 2014 [26]. With the difference of long-term clinical outcomes from Western registries, we developed a new risk score, KAMIR score, had more simplicity and accuracy for one-year mortality in 9
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Korea patients with AMI than the TIMI and Global Registry of Acute Coronary Events (GRACE) score [27,28]. Our study has limitations. First, selection bias cannot be avoided due to a retrospective observational study. Second, in order to reflect the real-world clinical data in patients with
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AMI, indexes were updated several times during study period. As a result, some of index, had less number of enrolled patients compared with other indexes and residual confounding also was remained. Nonetheless, it could be possible to understand the trends of patients with AMI
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because of large number of enrolled patients.
In conclusion, our study showed several trends of characteristics in Korean patients with AMI. Our findings provide information and evidence regarding management and treatment for Korean patients with AMI. In addition, guidelines for Asian patients with AMI should be
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Acknowledgments
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needed due to the differences in between Asia and Western patients with AMI.
This study was performed with the support of the Korean Circulation Society (KCS) as a
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memorandum of the 50th Anniversary of the KCS and the Korean Ministry of Health and
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Welfare, Republic of Korea.
Disclosures
The authors have no conflict of interest to disclose.
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Kim HK, Jeong MH, Ahn Y, Kim JH, Chae SC, Kim YJ, Hur SH, Seong IW, Hong TJ, Choi DH, Cho MC, Kim CJ, Seung KB, Chung WS, Jang YS, Rha SW, Bae JH, Cho JG, Park SJ; other Korea Acute Myocardial Infarction Registry Investigators; Korea Acute Myocardial Infarction Registry (KAMIR) Study Group of Korean Circulation
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Figure legends
Figure 1. Changing trends in vascular access in patients with AMI (A), STEMI (B), and 18
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NSTEMI (C). Abbreviations: AMI, acute myocardial infarction; NSTEMI, non-ST-elevation myocardial
AC
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infarction; STEMI, ST-elevation myocardial infarction.
Figure 2. Annual primary PCI rate in patients with STEMI (A), PCI rates in patients with 19
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AMI and both STEMI and NSTEMI (B). Abbreviation: AMI, acute myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; STEMI, ST-elevation myocardial infarction; PCI, percutaneous coronary
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intervention.
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Figure 3. The proportion of DES and BMS implantation in patients with STEMI from 2005
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and 2016. Abbreviations: BMS, bare metal stent; DES, drug-eluting stent; STEMI, ST-
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elevation myocardial infarction.
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Figure 4. Temporal trend in one-year mortality between 2005 and 2015.
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Table 1. Procedural and coronary angiographic characteristics and in-hospital outcomes of patients hospitalized with AMI between 2005 and 2016.
AMI (n=54,402)
Total
No.
no. Primary PCI for
STEMI
NSTEMI
(n=29,222)
(n=25,180)
Total no.
-
27,669
STEMI
24,296
-
18,877
4,658
-
(24.7%)
Radial access
34,223
10,100
Image-guided PCI
34,611
19,124
7,394
18,204
ED
(21.4%)
53,754
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Performed PCI
CE
45,735
Post-PCI TIMI 3
43,624
flow
46,941
29,090
26,574
16,407
27,217
25,851
25,263
23,254
24,664
coronary artery
22
<0.001
(38.0%) 3,626
0.001
19,724
<0.001
(80.0%) 19,161
18,765
<0.001
(97.9%) 18,361
(92.0%) 27,067
5,744
(22.1%)
(97.3%)
(93.1%) 47,240
3,768
(93.6%)
(97.6%) 40,607
15,099
(20.7%)
(87.3%) 44,616
4,356
(22.8%)
M
(29.5%)
AC
No.
no.
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-
aspiration
Infarct-related
Total
Value*
(87.8%)
Thrombus
Successful PCI
No.
p
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Variables
17,353
<0.001
(94.5%) 20,173
<0.001
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descending Left circumflex
Right
Left main
Involved
vessel
22,263
13,848
8,415
(47.1%)
(51.2%)
(41.7%)
8,044
2,623
5,421
(17.0%)
(9.7%)
(26.9%)
15,834
10,144
5,690
(33.5%)
(37.5%)
(28.2%)
1,099
452
647
(2.3%)
(1.7%)
47,124
26,989
type Single vessel
21,667 (46.0%)
main
or
25,457
M
Left
(54.0%)
ACC/AHA B2/C
ED
multivessel 43,440
46,566
CE
Stenting for target lesion
24,825
(80.6%)
PT
lesion
35,000
42,027
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anterior
(3.2%)
20,135
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Left
13,519
8,148
(50.1%)
(40.5%)
13,470
11,987
(49.9%)
(59.5%)
20,213
18,615
(81.4%) 26,872
<0.001
24,651
14,787 (79.4%)
19,684
17,376
(90.3%)
(91.7%)
(88.3%)
38,772
22,592
16,180
(94.0%)
(93.5%)
(94.8%)
2,367
1,527
840
AC
Type of implanted stent
Drug-eluting
stent Bare-metal stent
23
<0.001
<0.001
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(5.8%)
(6.3%)
(4.9%)
Bioresorbable
87
43
44
vascular scaffold
(0.2%)
(0.2%)
(0.3%)
Implanted
stent,
No. of stents per 13,869 target lesion
(0.43%)
diameter 41,469
per lesion, mm Stented
3.15
length
41,087
26.3 (10.3%)
No. of stents per 43,541
(0.85%)
outcomes
51,352
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Length of stay, mean (SD), days
54,059
AC
CE
In-hospital death
Cardiac death†
6,677
3.19
24,113
26.1
17,136
1.36
3.09
16,974
18,904
26.6
1.44 (0.96%)
8.2
8.2
8.3
(9.5%)
(9.6%)
(9.4%)
28,990
1,650
25,069
828
(4.6%)
(5.7%)
(3.3%)
1,972
1,365
607
(79.6%)
(82.7%)
(73.3%)
507
285
221
(20.4%)
(17.3%)
(26.7%)
24
<0.001
<0.001
(11.4%)
(0.75%)
2,478
<0.001
(0.44%)
(9.4%)
24,637
1.21
(0.46%)
(0.44%)
ED
In-hospital
Non-cardiac
24,333
M
patient
1.40
1.17
(0.40%)
(0.44%)
per lesion, mm
death‡
7,192
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Stent
1.19
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mean (SD)
<0.001
0.057
<0.001
<0.001
<0.001
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Data are expressed as No. (%) unless otherwise indicated * † ‡
STEMI vs. NSTEMI. Pump failure, arrhythmia, and mechanical complication. Multi-organ failure, bleeding, sepsis, others.
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Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; AMI, acute myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIMI, Thrombolysis In
AC
CE
PT
ED
M
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Myocardial Infarction.
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Table 2. Antiplatelet medications at discharge between 2005 and 2016.
STEMI
NSTEMI
(n=54,402)
(n=29,222)
(n=25,180)
Total
No.
Total
no. DAPT
no.
49,332
45,339
26,347
(91.9%) 49,541
48,166 (97.2%)
P2Y12
49,249
receptor
46,039 (93.5%)
Clopidogrel
46,039
40,986
26,353
25,270
ED 3,622
PT
46,039
(7.9%)
46,039
1,431
25,270
22,487
1,955
22,896
20,769
(3.1%)
828
<0.001
22,303
<0.001
(96.5%) 20,769
<0.001
(90.7%)
18,499
0.78
(89.1%) 20,769
(7.7%) 25,270
20,603
1,667
0.250
(8.0%) 20,769
(3.3%)
603
0.022
(2.9%)
AC
CE
Prasugrel
23,101
(89.0%) 25,270
Value*
(89.6%)
(95.9%)
(89.0%)
Ticagrelor
25,863
22,985
(97.8%)
M
inhibitor
24,796
p
No.
no.
(94.1%) 26,440
Total
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Aspirin
No.
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Variable
AMI
Data expressed as No. (%) *
STEMI vs. NSTEMI.
Abbreviations: AMI, acute myocardial infarction; DAPT, dual antiplatelet therapy; NSTEMI, non-STelevation myocardial infarction; STEMI, ST-elevation myocardial infarction.
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Table 3. One-year cumulative clinical outcomes from 2005 to 2015. STEMI
NSTEMI
(n=51,019)
(n=29,222)
(n=25,180)
Total
No.
no.
Total
No.
no.
One-year follow-
18,271
3,630 (10.6%)
Cardiac death†
34,337
2,758 (8.0%)
34,337
death ‡ 34,337
infarction
PT
590
590
AC
NSTEMI
34,337
CABG
34,337
Repeat PCI
590
197
18,271
18,271
243
243
460
16,066
(2.5%) 243
140
103
18,271
1,031
16,066
(0.4%)
54 (0.3%)
27
<0.001
(9.5%) 1,119
<0.001
(7.0%) 412
0.53
347
<0.001
(2.2%) 347
57
<0.001
(16.4%) 347
290
<0.001
(83.6%) 16,066
(5.6%) 18,271
1,531
(2.6%)
(42.4%)
(5.5%) 129
16,066
(57.6%)
(66.6%) 1,880
1,639
(1.3%)
(33.4%) 393
16,066
(9.0%)
(1.7%)
CE
STEMI
18,271
(2.6%)
ED
Myocardial
872
2,099 (11.5%)
M
Non-cardiac
18,271
Value*
16,066
AN US
34,337
p
No.
no.
up All-cause death
Total
CR IP T
Variables
AMI
849
0.18
(5.3%) 16,066
75 (0.5%)
0.010
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Definite
stent
28,883
thrombosis
147
86
61
(0.5%)
(0.6%)
(0.4%)
Type of definite
0.097
0.051
stent thrombosis 147
14
86
8 (9.3%)
86
42
(9.5%) Subacute
147
59 (40.1%)
147
55 (40.5%)
Very late
147
19
Data expressed as number (%).
†
(12.8%)
0.011
61
61
30
0.013
(49.2%) 8
0.95
(13.1%)
Pump failure, arrhythmia, mechanical complication. Multi-organ failure, bleeding, sepsis, others.
PT
‡
STEMI vs. NSTEMI.
11
17
(27.9%)
(29.1%)
86
0.91
ED
*
25
6 (9.8%)
M
(12.9%)
86
61
AN US
Late
(48.8%)
61
CR IP T
Acute
Abbreviations: AMI, acute myocardial infarction; CABG, coronary-artery bypass surgery; NSTEMI,
CE
non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-
AC
elevation myocardial infarction.
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